Incomplete Medical Records and Medication Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident with dementia and severe cognitive impairment, the healthcare proxy (HCP) activation form was not fully completed. Specifically, the section requiring documentation of the cause and nature of the resident's incapacity was left blank by the nurse practitioner who invoked the HCP. Both the Director of Nursing (DON) and the Administrator confirmed that the form was incomplete, making the medical record inaccurate for this resident. For another resident admitted with spinal stenosis and post-laminectomy, the administration of Tramadol, a pain medication, was not consistently documented on the Medication Administration Record (MAR). Although the narcotic count book showed that 13 doses of Tramadol were dispensed over several days, these administrations were not recorded on the MAR. The nurse responsible acknowledged that she had administered the medication but failed to document it as required. Interviews with facility staff, including the DON and the Administrator, confirmed that the expectation is for all medication administrations and relevant medical information to be accurately and completely documented in the residents' medical records. The lack of documentation resulted in incomplete and potentially inaccurate records for both residents involved.